MEDICARE: AUSTIN WYSS ATC/LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	36001599A	IN

General Provider Information

NPI Number	:	1467814939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUSTIN WYSS ATC/LAT

Provider Business Mailing Address
First Line	:	11130 PARKVIEW CIRCLE DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1735
Country	:	US
Telephone Number	:	260-385-6292
Fax Number	:

Provider Business Practice Location Address
First Line	:	11130 PARKVIEW CIRCLE DRIVE
Second Line	:
City	:	FT. WAYNE
State	:	IN
Zip	:	46845
Country	:	US
Telephone Number	:	260-385-6292
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2016
Last Update Date	:	03/24/2016

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